APPENDIX 2

Implementing Delivering quality health for Hertfordshire:

proposed changes to surgical services at the Lister and QEII hospitals by mid-2011

Briefing paper for HertfordshireCounty Council Health Scrutiny Committee

  1. Introduction

The purpose of this paper is to brief members of the council’s Health Scrutiny Committee on proposals that the Trust is discussing formally with its staff around changes to surgical services at the Lister and QEII hospitals that will need to follow on from the Lister Surgicentre’s opening. This service is scheduled to commence in April 2011.

From this date, virtually all of the Trust’s day case surgery, along with most short stay orthopaedic procedures, carried out at the Lister and QEII currently,transfer to the Surgicentre. A major consequence of this change will be that the Trust’s remaining surgical services will be fragmented and not arranged in a way that helps to ensure the best clinical outcomes for patients.

As indicated throughout the Delivering quality health care for Hertfordshire public consultation and decision-making process, the opening of the Lister Surgicentre requires the Trust to reorganise its remaining surgical services to:

  • Ensure that they remain clinically safe and effective;
  • Take opportunities to improve clinical outcomes for patients;
  • Be efficient and effective in terms of use of NHS resources.

Once the above criteria have been met, the Trust will also seek to ensure that the proposed changes are aligned with the Trust’s commitment to implementing the phase four outline business case for the redevelopment of the Lister by 2014, which forms part of county-wide Delivering quality health care for Hertfordshire health strategy.

From mid-April 2011, which is when the majority of surgical changes will take place, it is important to stress that both the Lister and QEII’s A&E departments will remain open. The Trust has also commenced discussion with the ambulance service on securing agreed protocols that ensure that blue light cases are transferred to the right hospital for a patient’s emergency surgery. In particular, the QEII will retain the capability of caring for someone who is too unwell to be transferred should they self-present or whose condition deteriorates rapidly once in hospital.

  1. Context – principles underlying change

The Trust’s proposed changes are based on three underlying principles, namely to:

  • Improve continuously the quality of care that patients receive;
  • Move more non-emergency and non-specialist hospital care closer to where people live, whilst at the same time ensuring that patients are neither admitted to hospital needlessly, nor stay longer as an inpatient than is necessary;
  • Continue responding to the UK’s current economic climate that will see low real term growth in NHS budgets. This means that all NHS organisations will need to find, year-on-year, increasingly cost-effective ways of delivering higher quality services to their patients.

This paper builds, therefore, on information shared with the Health Scrutiny Committee on 5 August 2010 around the Trust’s initial approach discussed previously around proposed changes for trauma and orthopaedic surgery.

3. Proposed surgical and medical service changes

The main changes proposed for the Lister and QEII surgical services, along with their proposed phasing, are set out in the table below. The committee is asked to note that feedback from staff and the public during the pending phase of formal discussion and engagement may lead to changes to these proposals.

Mid-April 2011
  • Lister Surgicentre opens
  • Lister day surgery unit closes – majority of work transfers to the new Surgicentre
  • Essendon eye theatre closes – majority of the work transfers to the new Surgicentre
  • Reduction in elective inpatient services at the Lister and QEII both sites – 23-hour stay and orthopaedic joints transferring to the new Surgicentre
  • Centralisation of Trust’s remaining day surgery at the QEII ‘s day surgery services on Queens Wing and Essendon ward
  • All of the Trust’s remaining elective orthopaedics surgery brought to the theatres on Princes Wing, with only that requiring input from the Trust’s interventional cardiology or renal teams being carried out at the Lister where these two services are based
  • All fractured neck of femur surgery across the Trust carried out in Princes Wing theatres
  • All trauma cases (except for fractured neck of femur) brought together at the Lister
  • All of the Trust’s emergency general surgery brought together at the Lister
  • Dedicated plastics trauma theatre sessions at the Lister

November 2011
  • New maternity unit at the Lister opened October 2011
  • All inpatient obstetric and gynaecological services brought together at the Lister
  • Reduction in number of elective sessions in the QEII’s main theatres

While it is proposed that inpatient surgical services at the Lister and QEII will change, from mid-April 2011 both hospitals will retain:

  • Outpatient services
  • Pre-assessment services
  • Critical care cover to both sites
  • Emergency surgery capability at both sites
  • Planned (elective) inpatient surgery on both sites
  • A&E department services on both sites

Some of these services may undergo further change before early 2014, which is when phase four of the Lister’s redevelopment is scheduled currently to be complete. This is the latest point that all remaining emergency and planned inpatient care at the QEII will have transferred to the Lister. It is also when NHS Hertfordshire’s new QEII hospital is expected to be built, which will include a local A&E service.

  1. Impact on patients

The expected benefit of the Trust’s proposed surgical changes on patients will be to:

  • Provide faster access to high-quality emergency and planned surgical care that enables them to recover more quickly – especially for patients with fractured neck of femur in older patients;
  • Make sure that the right level of support is in place so that those patients who are admitted can be discharged more effectively;
  • Reduce further mortality and morbidity rates associated with the Trust’s surgical services.

Emergency surgery

In making these changes, the Trust recognises that the ambulance service will follow protocols, to be agreed, that will result in patients being taken quickly to the right hospital for their emergency surgery. Based on historical data collated by the Trust, once these new surgical arrangements are put in place:

  • Around 240 people who would have received surgery for a fractured neck of femur at the Lister will go to the QEII;
  • Some 660people who undergo emergency general surgery at the QEII currently will instead be taken to the Lister.

Of these roughly 900 patients, a large proportion will be taken to the right hospital by ambulance, in line with the protocol to be agreed with the ambulance service. People making their own way to hospital will be unlikely to have critical conditions.

Where this is the case, however, procedures will be in place to ensure that the patient is assessed and the right treatment path is followed – which in most cases will involve transfer to the right hospital.

Planned surgery

The majority of the Trust’s existing planned inpatient surgery will remain unaffected apart from:

  • The vast majority of the Trust’s planned orthopaedic surgery will be provided through Princes Wing at the QEII, with only that requiring input from the Trust’s interventional cardiology or renal teams being carried out at the Lister where these two services are based;
  • All day surgery that remains with the Trust (for patients who do not meet the criteria for treatment within the Surgicentre) will be moved to the QEII;
  1. Impact on Lister and QEII wards and operating theatres

As stated previously, the creation of the Lister Surgicentre – which will have 26 inpatient beds – leaves the Trust with a very different case mix, comprising more complex surgery and patients who require longer periods of recovery in hospital. Through streamlining its remaining surgical services in the way described in this briefing paper, the Trust will have a need for 31 less inpatient beds than is the case currently.

The majority of this change – 26 beds – represents a transfer of care to the Lister Surgicentre. In addition, the Trust is working on plans to create an additional two critical care beds at the Lister – see below for more information. Between these two initiatives, therefore, this leaves the Trust with an overall net reduction of just three beds out of a total bed stock across the Lister and QEII of some 850 beds.

While all of the Trust’s surgical wards, to a greater or lesser degree, will see a change in the case mix of patients for whom they care once the Lister Surgicentre opens, the main ward changes that will take place within the Trust’s remaining services are as follows:

  • Ward 7B at the Lister, which currently is for short stay surgery patients only, will change to supporting both short and longer stay patients;
  • The critical care service at the Lister, which is where a greater percentage of the Trust’s emergency surgery will be taking place, will see two critical care beds transferring to the hospital from the QEII. Overall the Trust’s critical care capacity will remain unchanged;
  • In recognition of a general increase in use of critical care services across the Trust, a plan is being worked up for the creation of an additional three critical care beds at the Lister;
  • From April 2011, the percentage of the Trust’s surgery taking place on the Lister site will have increased significantly. As a result, LemsfordWard, one of the QEII’s existing surgical wards is expected to be closed.

Given the number of bed changes involved in these proposals, including service moves to the Lister Surgicentre, the Trust’s staffing establishment will also be reduced. Whilst the precise numbers involved will be dependent on how many people move to work in the Surgicentre, the Trust remains confident that this process can be managed without the need for clinical redundancies. It may mean, however, that some staff will need to work in a different part of their existing hospital or move between the Lister and QEII.

In terms of the impact of the proposed changes on the Lister and QEII’s current operating theatres, the nature and number of surgical cases going through them will be significantly different. The timetables used by the Trust for medical and theatre staff, as well as for each theatre suite, will need to change to accommodate the following:

  • The need to accommodate emergency and elective work in the Lister’s main theatres;
  • Linking with the Surgicentre’s operating timetable, which obviously will involve the Trust’s staff;
  • Transferring day surgery remaining with the Trust from two units to the one currently at the QEII;
  • The physical location of the Trust’s existing operating theatres across the Lister and QEII sites;
  • The move of surgical specialties between sites and theatres.
  1. Further planned changes

It is proposed that revised surgical care pathways being introduced by the Trust will be monitored to ensure that they deliver the proposed bed savings, as well as anticipated improvements in both clinical outcomes and patient experience.

A full review will be undertaken six months post implementation of each of the schemes listed, which can also be used to scope further service changes based on the effectiveness of these revised models of care, as well as changes in activity levels from 2011 reflecting commissioners’ intended reductions in referrals to the acute hospital services.

In June 2010, the Trust provided the Health Scrutiny Committee with a briefing paper outlining a series of proposed changes to medical services at both the Lister and QEII. Principally these related to creating new ambulatory care centres and medical day units at both hospitals.

The changes to the Lister services are in the process of taking place, following a successful staff consultation that took place earlier this year. The clinical staff affected by the changes were retained by the Trust in new roles at the hospital, including in the new ambulatory care centre and medical day unit. Consultation with QEII staff on making similar changes at the hospital are expected to start in early 2011, with the new services scheduled to be ready by the middle of that year.

In the past, the NHS in Hertfordshire has also discussed the clinical importance of bringing the Trust’s acute stroke services together at the Lister. Not only does this represent best clinical practice nationally, but will also provide far better outcomes for this particularly vulnerable group of patients. A detailed briefing paper on the Trust’s proposals will be shared with the Health Select Committee before the end of 2010.

As detailed earlier, the Trust is also developing plans to increase the overall capacity of its critical care service through creating two additional beds at the Lister.

In addition to the changes outlined in this and previous briefing papers provided to the Health Scrutiny Committee, 2011 will see the first two phases of the Trust’s Our changing hospitals programme – the Lister Surgicentre and new inpatient maternity service – opening to patients in April and October 2011 respectively.

Both of these new services will bring significant change to the Trust’s patients and staff. By the end of 2011, approximately 50% of all planned surgery provided currently at the QEII will have transferred to the Lister Surgicentre along with all hospital births.

  1. Current status of plans

Preliminary discussions have been had with a range of internal stakeholders, including clinical and managerial staff, the Trust’s Involvement Committee and Patients’ Panel in relation to the services outlined in this paper.The key outcomes of this preliminary piece of engagement work have been that:

  • The divisional team (clinicians and management) are supportive of plans to reconfigure these services;
  • The plans are consistent with the Trust’ strategic aims;
  • The proposals can be accommodated within the Trust’s existing estate;
  • The proposals support further improvements in both clinical efficiency and patient experience, as well as the provision of cost-effective acute care.

Further engagement and communication activities will be undertaken over the next two months, both internally and externally to the Trust, with the aim of understanding key stakeholders’ views on these proposals. This work will also form part of a detailed assessment of the impact and benefits of these plans.

  1. Next steps

Over the next three months the Trust will undertake further engagement with patients, carers and other health and social care staff, whilst also consulting with staff potentially affected by this next phase of service change. The table below provides an outline of the engagement plan that has been developed for this purpose.

Outline of patients and carers to be targeted for views / Issues on which views will be sought will include:
Relatives and carers
Patients’ Panel
Foundation trust appointed governors and members
LINks
GPs and PBCs
Voluntary and support groups supporting the elderly e.g. Age Concern, Alzheimer’s support groups
Disability groups including Hertfordshire Action on Disability.
Ambulance service
LSPs and local authorities
Adult care services /
  • What issues do we need to consider in planning the consolidation of these services?
  • How might the proposed changes affect you (or the group you are representing) – both positively and negatively effects
  • What might help address any difficulties you foresee?

Engagement activities will be undertaken in line with the Hertfordshire County Council Concordat and the Trust’s internal consultation protocol.

The Trust’sSurgicentre project teamwill lead on staff, patient and stakeholder consultation and engagement, with support provided by the Trust’s partnerships and involvement team. Engagement and consultation work will be underpinned by communications planning and support from the Trust’s communications team.

Following completion of this engagement phase, the Trust will review its proposed service changes and respond to information and views received.

Subject to Trust approval to proceed and agreement being reached with commissioners, the Trust’s final plans will be shared with representatives of the Health Scrutiny Committee in order to:

  • Confirm the outcomes of engagement and proposed timescale for service change implementation;
  • Seek confirmation from the Health Scrutiny Committee that the quality and extent of engagement has been satisfactory and that the proposals may proceed.
  1. Conclusion

In order to continue to improve the quality of acute specialist services and clinical outcomes, as well as to enhance clinical efficiency, the Trust is proposing to make changes to models of surgical care that will result in a reduction in the total number of inpatient beds and configuration of some specialist services.